Louisville Medicine Volume 66, Issue 11 | Page 31

OPINION DOCTORS' Lounge take money on many occasions, but said, “Save the money to buy food. You can pay me later.” During and after my 1967 internship year here at St. Joseph’s Infirmary, I was mentored by such men as Drs. John Hem- mer, Bernie Popham, Richard Roth, Frank Jelsma and Henry Asman. All of them were different in their own way, but they knew the importance of being a model for the younger generation. They spoke in a gentle manner (on most occasions), and they were respectable and respectful. They inspired respect by their speech and gesture. I always wanted to emulate them. The great concept that Drs. Hemmer and Jelsma taught me was, “You don’t have to agree with everyone but always be respectful. Others may not like that you disagree but, as long as your conscience is clear, you will have peace in your heart.” We must mentor the next generation. There were times during my private prac- tice when students from business school or medical students in community rotations came to learn the ways of the older gener- ation. The present focus on the business of medicine has changed the way we deliver care. There is less caring and more delivery. Now many, many doctors work for cor- porations, and have very little to say about the practice of medicine. We are told to code correctly and “higher” to generate more revenue. If the coding is lower and not enough money is brought in, we are told to have more education. The more money we generate, the more bureaucracy is built into the system, and we are provided with more managers to manage the doctors. I was surprised when microscopes were removed from certain facilities because it was determined by the “leadership” that “maybe the lab assistants were not properly trained to read the clue cells or white cells.” Therefore, we were told to run the urine dip as a print out and then send all urine for culture, “because there is a lot of anti- biotic resistance.” Most of the people who make such decisions usually do not work as doctors and cannot possibly fathom the im- portance of Leuwenhoek’s discovery. I was told that RVUs are important and coding is not really based on medical necessity, but medical decision making. There was a time when we, doctors, looked at the slides for malaria and white cells and giant cells and so on. It has become a lost art. In the mid-six- ties, we did our own microscopic readings. It is not for everyone to recognize Puffer cells of synovial sarcoma or poached egg cells of Oligodendroglioma, but that is not really what we are battling with these days. One of the most common causes of frus- tration is the practice of giving a bonus to the providers. Some criteria are prepared to make the system look equitable. But in reality, the providers (as insurers are called these days) are told in a very subtle manner to generate more revenue. One of my man- agers once told me that “Look if you don’t code higher, you are just giving benefit to the insurance company, not to the patient.” I swallowed my pride and listened. I was told that RVUs are important in deciding bonus and medical necessity is only one of the elements in deciding about coding for services. I remembered that I had gone to a local hospital for aspiration of some blood from my elbow, and after the procedure was finished I asked for a Tylenol pill. When I received the bill, I noticed there was an additional charge for ten dollars, and so I called the administrator of the hospital com- plaining about the charge. He reminded me that, when we check into a hotel, the actual payment is not what is written on the back of the door in the room. There are times when a company moni- tor is assigned to check on a doctor’s coding practices; to me that felt like intimidation. I feel that as doctors we must resist such controlling behavior and do only what we believe is right. The New England Journal of Medicine (NEJM) published an article about the bo- nus system and how it corrupts doctors. Aristotle had said (I am paraphrasing) that we are humans first, and next we are our oc- cupation. I do not wish to pillory the system without an answer or solution. I believe we should be judged by our patients and our subordinates, and not by our colleagues whom we play golf with, and not by how we consider coding and charges. Dr. D. Khullar et al. in the NEJM of June 11, 2015, addressed the issue of “Behavioral economics and physician compensation— promise and challenges.” It took us many years to recognize that we need second opinions before removing the uterus from someone and slowly we are moving towards a similar phenomenon before performing lumbar fusions for disc degeneration. Nu- merous series (three in sequence) of epi- dural injections are given to patients with back pain, despite studies that have shown that there are no long-term benefits and the effects are equal to placebo at best. I think we have to be mentors for the next generation and teach evidence-based medicine. Dr. William E. Hunt, in his 1971 presidential address to the Neurosurgical Society of America, said that if we act as business entrepreneurs, we will be treated as such by society. We will lose the privilege we enjoy from being doctors and profession- als. 1 Timothy 6:10 said it best: “The love of money is the root of all evil.” We often forget that as we continue our journey of medicine. We are obviously bright in high school; we excelled as undergrads to get into medical school, and most of us grew up with a sense of morality. The enticement of the dollar is genuine and I feel it has to be quelled in our heart in a deliberate manner. Otherwise we might end up justifying our actions to seek advantage. The NEJM article stated, “Behavioral economics views incentives as fundamental determinants of behavior, and it can help elucidate how the timing, frequency and amount of payment influence behavior.” I never forget the fact that I try to see myself in the best image possible and there are times when my sense of entitlement might interfere with listening to advice contrary to that self-perception. Physicians, be self- aware. Dr. Banerjee is the Clinical Professor of Neuro- surgery at the University of Louisville. APRIL 2019 29